C PRESCRIPTION DRUG PRIOR AUTHORIZATION OR …

1 Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 1 of 10 GR-69025-CA (5-17) Fax this form to: 1-877-269-9916 For specialty drugs fax to: 1-888-267-3277 OR Submit your request online at: CALIFORNIA PRESCRIPTION drug PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORMPlan/Medical Group Name: _____ Plan/Medical Group Phone#: (_____) Plan/Medical Group Fax#: (_____)_____ Non-Urgent Exigent Circumstances Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, chart notes or lab data, to support the PRIOR AUTHORIZATION or step-therapy exception request.

2 Information contained in this form is Protected Health Information under HIPAA. Patient Information First Name: Last Name: MI: Phone Number: Address:City:State:Zip Code:Date of Birth: Male Female Circle unit of measure Height (in/cm): _____Weight (lb/kg):_____ Allergies: Patient s Authorized Representative (if applicable): Authorized Representative Phone Number: Insurance Information Primary Insurance Name: Patient ID Number: Secondary Insurance Name: Patient ID Number: Prescriber Information First Name: Last Name: Specialty: Address:City:State:Zip Code:Requestor (if different than prescriber): Office Contact Person: NPI Number (individual): Phone Number.

3 DEA Number (if required): Fax Number (in HIPAA compliant area): Email Address: Medication / Medical and Dispensing Information Medication Name: New Therapy Renewal Step Therapy Exception Request If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): How did the patient receive the medication? Paid under Insurance Name: PRIOR Auth. Number (if known): Other (explain): Dose/Strength:Frequency:Length ofTherapy/#Refills: Quantity:Administration: Oral/SL Topical Injection IV Other: Administration Location: Physician s Office Ambulatory Infusion Center Patient s Home Home Care Agency Outpatient Hospital Care Long Term Care Other (explain): Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 2 of 10 GR-69025-CA (5-17) Fax this form to: 1-877-269-9916 For specialty drugs fax to: 1-888-267-3277 OR Submit your request online at.

4 CALIFORNIA PRESCRIPTION drug PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORMP atient Name: ID#: Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, chart notes or lab data, to support the PRIOR AUTHORIZATION or step therapy exception request. 1. Has the patient tried any other medications for this condition?YES (if yes, complete below) NOMedication/Therapy (Specify drug Name and Dosage) Duration of Therapy (Specify Dates) Response/Reason for Failure/Allergy 2. List Diagnoses:ICD-10: 3.

5 Required clinical information - Please provide all relevant clinical information to support a PRIOR AUTHORIZATION or step therapyexception request review. Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug . Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage, including information related to exigent circumstances, or required under state and federal laws.

6 Attachments Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form. Prescriber Signature or Electronic Verification:Date:Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited.

7 If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents. Plan/Insurer Use Only: Date/Time Request Received by Plan/Insurer: _____ Date/Time of Decision_____ _Fax Number ( ) _____ Approved Denied Comments/Information Requested: Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 3 of 10 GR-69025-CA (5-17) aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

8 aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at , or at.

9 Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD). aetna is the brand name used for products and services provided by one or more of the aetna group of subsidiary companies, including aetna Life Insurance Company, Coventry Health Care plans and their affiliates ( aetna ). Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 4 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 5 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 6 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 7 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 8 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 9 of 10 GR-69025-CA (5-17) Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 10 of 10 GR-69025-CA (5-17)

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